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A 25-year-old female with primary malignant fibrous histiocytoma of the distal fibula is presented. Malignant fibrous histiocytoma of bone is a rare primary bone tumor in this anatomic location. Careful preoperative staging studies and neoadjunct chemotherapy permitted an unusual resection to be performed resulting in successful limb salvage for the patient.
Thirty-two patients who had ablation of the foot by the Syme or Boyd technique for partial or total absence of the fibula, with subsequent fitting of a prosthesis, were compared with eleven patients who had lengthening of the lower limb by the Wagner method, to assess the long-term results of each procedure. The final results were evaluated on the basis of pain, limp, limb-length discrepancy, level of physical activity, and satisfaction of the patient. Of the thirty-two patients who had an amputation, twenty-eight (88 per cent) had a satisfactory result, compared with only six (55 per cent) of the eleven patients who had limb-lengthening. The amount of inequality between the lower limbs was classified as follows: Group I--the foot of the shorter extremity was at the distal third of the contralateral, normal limb, and the percentage of shortening was 15 per cent or less; Group II--the foot of the shorter extremity was at the level of the middle third of the contralateral, normal limb, and the percentage of shortening was between 16 and 25 per cent; and Group III--the foot of the shorter extremity was at the level of the proximal third of the contralateral, normal limb, and the percentage of shortening was greater than 26 per cent. Lengthening was best suited for patients in Group I who had stable hips, knees, and ankles and a plantigrade foot. Patients in Groups II and III were best served by ablation of the foot and fitting of a prosthesis.
A 3 1/2-year-old girl presented with a lytic lesion in the diametaphyseal region of the right fibula. In addition to plain roentgenography, radiological evaluation consisted of bone scintigraphy and computed tomography. The radiological features suggested a benign lesion. Pathological examination revealed a chondromyxoid fibroma.
The fibula was investigated as a donor site for free-flap mandible reconstruction. It has the advantages of consistent shape, ample length, distant location to allow a two-team approach, and low donor-site morbidity. It can be raised with a skin island for composite-tissue reconstruction. Twelve segmental mandibular defects (average 13.5 cm) were reconstructed following resection for tumor, most commonly epidermoid carcinoma. Five defects consisted of bone alone, and four others had only a small amount of associated intraoral soft-tissue loss. Eleven patients underwent primary reconstructions. At least two osteotomies were performed on each graft, and miniplates were used for fixation in 11 patients. Six patients received postoperative radiation, and two patients received postoperative chemotherapy. The flaps survived in all patients. All osteotomies healed primarily. The septocutaneous blood supply was generally not adequate to support a skin island for intraoral soft-tissue replacement. The aesthetic result of the reconstruction was excellent in most patients, particularly in "bone only" defects. There was no long-term donor-site morbidity.
This paper describes a clinical application of the free vascularized fibula graft to the anterior cervical fusion and its long-term post-operative results. We performed the above operation on six patients with disorders of the cervical spine at multiple intervertebral levels. 1) All grafts were successfully united between 2.5 and 5 months (mean 3.4 months). 2) Similar operations performed experimentally on a rabbit model indicated that muscle sleeves surrounding vascularized bone grafts were replaced by fat tissue and did not ossificate through 'metaplasia'. The experiment further showed that partial bone union was possible mediated through fat tissue. In clinical cases, post-operative CT demonstrated bone union between the middle of the grafted bone and vertebral body. 3) The present procedure appears to be superior to conventional methods which produce occasional delayed bone union and pseudoarthrosis formation, therefore, is recommended highly for a treatment of the anterior body fusion of the cervical spine involved with more than three intervertebral discs.
In the treatment of open fractures of the lower limb and of fractures combined with severe damage of soft tissues, external fixation is favoured. Additional soft tissue damages in the compartments of the lower limb are avoided by using an external fixation in form of a clamp. In defect fractures, shattered fractures and in all fractures in the distal third the stability of clamp fixation is enhanced by plating of the fibula. Furthermore by osteosynthesis the reconstruction of the correct length of the lower limb can be performed. 36 fractures healed definitively in an average of 17.1 weeks by this procedure. Secondary procedures were: 8 cases with decompression of compartments, 11 cancellous bone grafts, 13 fixateur externes were removed because of the infection of the Schanz'screws, and healing was achieved by using a plaster cast. The therapeutical procedure was changed in 5 patients to a plate osteosynthesis and in 8 patients to an intramedullary nail.
Two cases are presented in which allograft reconstruction followed wide resection of recurrent, aggressive aneurysmal bone cysts of the distal fibula. The authors find that allograft implantation provides a safe and effective method of reconstruction.
Sixty-six consecutive tenodeses of the tendo achillis to the fibula were done in sixty patients who had paralytic pes calcaneus. The patients were followed for an average of 5.7 years (range, two to 10.8 years). The preoperative disturbance of gait was eliminated in all of the patients, and radiographic improvement was noted in the feet that had been operated on. Sixteen feet (23 per cent) required revision of the tenodesis because equinus deformity had developed. The development of equinus deformity was found to occur more often in patients who had the procedure at a younger age and in patients in whom the calcaneotibial angle measured more than 70 degrees at the time of the tenodesis. Residual cavovarus deformity was successfully treated by a plantar release.
Dragan Dj./Re. No. 2755/76, 5,5-year-old boy, referred to this hospital with signs of bipolar osteomyelitis, destruction and fistulisation of the left tibia and talocrural arthritis. Staphylococcus albus and streptococcus haemoliticus were isolated from the fistula. Osteomyelitis was treated with an adequate therapy including long usage of Lincocin. In Feb. and Oct. of 1977 a sequestrotomy of the mid portion of the tibia and transmedular fixation using Ratschmann's nail were performed. The process resulted in pseudarthrosis of the mid portion of the tibia with loss of bone substance in the length of 2.5 cm and talocrural arthrosis and deformed foot. The boy walking support. In July 1980, in the stage of "ripe" pseudarthrosis a complete resection of pseudoarthrosis with sclerotic portions of tibia to healthy bone was performed. The mid part of the right tibia was resected subperiostally and was grafted centromedularlly into the upper and lower medular channel of the left tibia. Two Kirschner's needles were implanted centromedularlly so as to strengthen the bone osteosynthesis. Complete union of the grafted fibula with treppassage of the medular channel occurred with its tibilisation and growth in length and width. In July 1982, the concave foot was corrected using Bertrand's method. The present difference in the length between the two legs is 4.5 cm which is corrected by the use of padded shoes. Lengthening of the leg is planned to be performed before he reaches the age of 14.
Operative treatment for cervical spondylotic myelopathy and myeloradiculopathy by anterior decompression produced functional improvement of one grade (Nurick's rating system) in 16 of 21 patients evaluated at 32 months average follow-up period. The best results occurred in patients with symptoms for less than one year and classified as grades I-III. The anterior approach for decompression is preferred because it is directed toward the degenerative structures responsible for cord and root compression. The autogeneic fibula dove-tailed strut graft is favored over an iliac crest bone graft because with multilevel decompression in the cervical spine, it provided structural stability and a high union rate. There were no neurologic complications in this series of 21 cases.
Three patients with bone tumours were treated by radical resection and reconstruction of the missing bone segment by a vascularised fibula transplant. The surgical technique and early results are described.
The authors have treated 63 septic fractures of the tibia, 29 of whom were seen less than four months after the injury; the remainder were more long-standing. In both series the surgeon faced three problems--curing of the septic drainage, skin cover and bone union. In 46 cases bone excision was considered necessary: in 18 diaphyseal resection was performed. Immobilisation of the fracture was obtained by plaster cast in 14 cases, an external fixator in 48 cases, and medullary nailing in one. Reconstruction was needed in 11 cases after closed grafting, 9 of them being tibio-fibular, and in 46 after cancellous graft without skin closure. The results in 63 cases were 61 unions: 43 primary unions, 19 additional procedures to reinforce callus and 1 amputation. In two patients union remained particularly tenuous. Two patients are still showing discharge and 9 have poor skin cover. The average time to bone union was nine months and was twelve months in cases of resections greater than 3 cms. The authors are in favour of a technique of massive cancellous bone grafting of the tibia, aligned towards the fibula with partial skin closure. This procedure leads to a firmer and more rapid bone union than the Papineau technique. Secondary bone or skin procedures were needed less often. Tibio-fibular grafting was indicated in cases of limited infection and when the main tibial fragments were still uniting postero laterally.
Complete ulnas and fibulas were found in a 10-month-old Welsh Pony examined because of severe flexural deformity, with carpal and tarsal valgus deformities, in all limbs. Presence of these normally vestigial structures is considered a form of atavism. At one week of age, periosteal transection was performed for the angular deformity, resulting in no improvement. When performing this procedure, the authors recommend transection of these vestigial structures if present.
Periosteal proprioceptive nerve receptors may act as mechanoreceptors of long bones during adaptive remodeling after fracture. They may also contribute to the mechanisms of coordinated functional activity of fractured limbs and thus inhibit harmful overloading of fracture callus. The area of proprioceptive nerve receptors around the distal part of the rat fibula was stripped surgically, and a standard fracture of the fibular shaft was produced. Animals failed to unite their fractures and developed mainly atrophic nonunions. Atrophy of ununited fragments was due to osteoclastic bone resorption. Atrophy of the bone fragments was aggravated if the legs were also subjected to sciatic denervation. Sciatic denervation alone, without removal of receptors, did not interfere with the union of fractures. The results indicate that the area of proprioceptive receptors in the rat tibiofibular bone is critical for the healing of fibular fractures. Because the effect on bone healing of receptor removal was not inhibited by sciatic denervation, the effect was not transmitted through spinal pathways of the sciatic nerve. The development of nonunions could not be explained by the surgical trauma alone. Aggravation of fibular atrophy by sectioning of the sciatic nerve suggests that some neural elements are associated with the phenomenon, either directly or indirectly through neuromuscular function.
Widening of the ankle mortise following fracture can be a subtle diagnosis requiring special radiographs to fully appreciate the extent of shortening and rotation of the fibula. Once this fibular shortening has been recognized, a lengthening and rotational osteotomy can be conducted with use of a special compression/distraction device and bone graft. A series of 23 cases demonstrates that reconstructive lengthening osteotomy is well worthwhile when there is absent or minimal osteoarthritic change, irrespective of the time from the original injury.
In a 70-year old female patient, a so-called idiopathic massive osteolysis with destruction of the proximal right femur within six months, was observed. Histologically, the following conditions were found at the time of resection: a stroma rich in fibres, with the inclusion of blood vessels, as well as an osteoclastic absorption which was still clearly active at the margins, besides marginally defined processes of bone formation. A good functional result without progressing osteolysis at the femur was achieved via a total endoprosthetic replacement of the right hip joint. Within the following three years, polycystic intramedullar osteolysis developed from a slight loosening of the spongiosa in the right head of the fibula. In contrast to the changes which had occurred at the femur, this was a clear case of a rare intraosseous lymphangioma.
In a retrospective trial 235 patients with fractures of the tibia and/or fibula shafts were followed up. In 16 cases non-union of the fracture occurred after closed reduction and plaster cast treatment. In 16 of these patients closed nailing of the tibia was performed 8--14 weeks after the accident. The healing of the fracture was uncomplicated and occurred in 10--14 weeks p. op. The results in primary nailing cases 8--14 days after the accident were much better than in cases treated with plaster casts, with regard to joint mobility, venous insufficiency and duration of treatment; however two serious complications occurred. In two patients, osteitis occurred after primary nailing of the tibia. Localisation of the fractures (distal part of the tibia) and type of the fracture (short torsion fracture) correlated more frequently with formation of non-union than the rare changes in blood chemistry observed in our study. We regard intramedullary nailing of the tibia as the best available method in treating non-union or pseudarthrosis of the tibia.
66 children who were admitted to the Surgical Department of the University Children's Hospital in Zurich because of transverse fracture of the distal tibia and fibula were followed up. They were treated conservatively by reduction followed by immobilization in a plaster of Paris cast reaching to the upper thigh; the foot was placed in the equinus position. Perfect axial reposition should be aimed at. If this cannot be achieved, a varus deformity of up to 6 degrees, a valgus deformity of up to 10 degrees and antecurvation of up to 10 degrees are permissible, as this malposition usually cures itself in time. If the malformation exceeds the limits described above, operative reduction and fixation should be carried out in children over 12 years of age. All children with malposition must be followed up for a long time to observe whether the malposition will gradually disappear and to ascertain whether static difficulties will occur and may have to be corrected by osteotomy.